Coding & Efficacy

What’s in a name? Not much, if you recall your high school Shakespeare. Names are labels that can be quite arbitrary, without much depth of meaning or significance.

But what happens when a name means nothing at all? That could be the argument against the current way that complex rehab technology (CRT) is described and grouped in reimbursement policies practiced by health insurance payors. Too often, the results are inadequate funding due to CRT products that are inaccurately and randomly defined and grouped with much more basic products that have very different applications. Ultimately, the consumer pays the price — especially when that consumer has significant, permanent disabilities.

HCPCS History

The American healthcare system is immense, with millions of patients to serve and billions of claims to process each year, according to the Centers for Medicare & Medicaid Services (CMS). No one would reasonably argue against the need for an efficient system to process and pay those claims.

“The Healthcare Common Procedure Coding System (HCPCS) was established in 1978 to provide a standardized means for CMS to describe the specific items and services provided in the delivery of health care,” Piriano explained. “The development and use of the Level II HCPCS codes, also known as alpha-numeric codes, began in the 1980s, at a time when the number of seating and wheeled mobility products available on the market was extremely limited.

“Coding ‘equivalent products’ is necessary for third-party payors to ensure claims are processed in a consistent manner. This also allows third-party payors to track utilization trends. According to CMS, there are national HCPCS codes representing approximately 6,000 separate categories of ‘like items’ or services that encompass millions of products from different manufacturers.”

While the HCPCS system has a long history, Piriano said it only more recently became the law of the land.

“Initially, use of the codes was voluntary,” she said. “But with the implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), use of the HCPCS for transactions involving health care information became mandatory.”

Rita Stanley is VP of Government Relations for Sunrise Medical. “While the basic intended use of the code set is for submitting a claim for payment,” she said, “Level II HCPCS codes serve as the foundation for coverage and payment for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). Fee schedules and coverage policies are created using HCPCS codes.”

Why “Any Type” Can Be Detrimental

Codes, however, have their limitations — especially when they’re seemingly expanded or stretched to include disparate products.

“Problems associated with HCPCS codes often stem from insufficient code requirements or characteristics,” Stanley said. “Vague and overly broad code descriptors are the most recent cause for a HCPCS code to become a barrier to access. Revisions to HCPCS code descriptors for CRT products frequently include the words Any Type. Payment associated with these codes have often been established based on the initial code and the products it included, and the fee schedule is not recalculated to include the new technology being forced into that code.

“The result is that a product has an assigned code, but the reimbursement is insufficient to allow access.”

Piriano agreed that the “Any Type” portion of a HCPCS code can be dangerous.

“When a code includes the words Any Type in the description, it gives rise to the inclusion of a wide array of dissimilar products and inaccurate payments being made by third-party payors,” she said. “CMS recognized this when they expanded the five power mobility device codes (E1230, K0010, K0011, K0012 and K0014) to 64 new HCPCS codes on Nov. 15, 2006. The bases were categorized into groups with similar performance characteristics, which allowed payors to establish reimbursement rates for ‘like products.’”

Stanley noted a similar skewing of payments when codes are rewritten to allow other products in.

As an example, she recalled that CMS “changed the descriptor for tilt in space, where the minimum requirement was equal to or greater than 40° of tilt. They decided they didn’t want to create a new code for all the [systems] below 40°, so they changed the code descriptor to ‘20° or more.’ But you’re really talking about clinically different [products] when you’re talking about a chair that only tilts 20° and one that tilts 60°.”

With the tilt requirement altered, tilt systems that only tilted back slightly were suddenly in the same code as systems that offered far more tilt. Systems that tilted slightly, mostly for reasons related to comfort, were now grouped with systems designed to provide clinically beneficial weight shifting and pressure management for users unable to weight shift on their own. The fact that both types of tilt systems are in the same code implies that the systems are very similar in function and functional goals.

“Now, all this different technology fits inside this same HCPCS code,” Stanley said. “They didn’t change the pricing when they did it, so now your products that only go to 20° are in the same code as products that go 60°. So in that case, one could argue that Medicare is paying too much for the 20°, because the fee schedule was created based on the greater degrees of tilt.”

Code Changes Impede Beneficiary Access

Unfortunately, there’s no shortage of examples of inappropriate coding or grouping that harms consumer access to CRT.

“In complex rehab, the industry has identified numerous HCPCS codes that include very dissimilar products — from very basic items of DME to highly configurable items of complex rehab technology — because there is only one code to describe a large group of items,” Piriano said. “While CMS has the authority to expand the code set and establish new descriptions that more accurately define the critical and configurable components individuals with disabilities use in connection with their mobility base, they have not shown a willingness to do so.”

In reality, there’s evidence that coding changes have expanded, blurred and diluted product definitions rather than more distinctly clarifying them.

“In 2003 there were unique HCPCS codes that defined manual wheelchair handrims made of aluminum (K0061) or steel (K0060), ones that were plastic coated (K0059), handrims that had eight to 10 vertical or oblique projections (K0062) and ones that had 12 to 16 vertical or oblique projections (K0063),” Piriano said. “Unfortunately, on Jan. 1, 2005, the unique codes K0059, K0060 and K0061 were not only no longer separately billable when provided with a manual wheelchair — they were consolidated into one HCPCS code (E2205), with the new description Manual Wheelchair Accessory, Handrim without Projections, Any Type, Replacement Only, Each. To further complicate the issue, when a clinically superior ergonomic handrim was developed and being brought to market, a unique HCPCS code was sought to accurately describe the technology. Instead of allowing a new HCPCS code to be added, CMS expanded the E2205 code description, effective Jan. 1, 2008, to include handrims that are ‘ergonomic or contoured’ as well.”

Stanley vividly remembered those handrim code changes. “[CMS] changed it to say Any type, including,” she said. “They literally added the name of the product to say, ‘Stop submitting HCPCS code requests. This is where your product goes.’

“But then they added ‘replacement only’ to the end of the descriptor, so now you can no longer bill for any type of handrim on initial issue.”

And Stanley remembered another example of impeded access.

“Another scenario is when we applied for the code for shoe holders and ankle huggers. And CMS said, ‘Looks like a toe loop/heel loop to me.’

“First of all, neither of those products looks anything like a toe loop or heel loop, and it wouldn’t take a huge leap, I don’t think, for most people to understand that a little webbed strap is far different from a manufacturing perspective than a shoe holder. But what [CMS] said was, ‘We’re going to say Toe loop/holder, any type,’ and just expanded it so nearly anything could go in the code. They did not recalculate the fee schedule, so that fee schedule was based strictly on toe loop technology replacement, essentially, probably based on supplier-submitted charges from the ’80s.”

From that example, Stanley said, “you can begin to see: I’ve got pricing that, when it was created, had nothing to do with this now-expanded definition of new technology that’s going into it.”

Ankle huggers and ergonomic or high-performance handrims are just the beginning. Stanley pointed out the current coding for headrests, compared to the headrest coding that had been used as recently as 2004:

“There are many examples of codes that contain CRT products where the technologies within the code vary in meaningful ways,” Stanley noted. “The products vary in features and function, clinical application, and costs to manufacture and provide. These products are not interchangeable to meet the medical needs of individuals.”

The Costs to Consumers

Ultimately, when HCPCS codes become bloated with dissimilar products thanks to descriptions that are stretched to accommodate more and more items, the consumer loses.

The danger is especially real and critical for CRT clients, who have very specific and complicated clinical needs and who need custom-fit or customized seating and mobility equipment.

But Piriano pointed out that such code scenarios can also be bad for payors.

“Clinically appropriate assistive technologies that meet the identified needs of an individual with disabilities are essential to their health, safety and well-being,” she said. “However, very basic to very complex items comprising the same HCPCS code, with one fee schedule, results in inaccurate reimbursement on both ends of the product spectrum.

“Basic items of DME are reimbursed at a high rate that makes them very profitable, which could entice providers to put profit over people. Conversely, highly configurable and complex rehab items that may have additional features or are made from technologically advanced materials are costlier, but reimbursed at an insufficient rate. This makes it very difficult for complex rehab companies to pay the manufacturer for the product and pay for the professional skills of the RESNA-certified Assistive Technology Professional (ATP) who is directly involved in the provision of the equipment. Clearly, with inadequate resources to provide necessary CRT products, the welfare of individuals with disabilities may be compromised.”

She added that imprecise HCPCS coding also makes it difficult to track the specific types of equipment being used.

“A lack of appropriate HCPCS codes to define the technologies provided for people with disabilities does not allow CMS or any other third-party payor to accurately capture the true utilization of these items. The risk is that there is, or will be, a misperception that these items are not used, or needed, further complicating access.”

Stanley said she’s been advised that if a CRT provider deems a Medicare allowable too low, the provider can handle the claim as a non-assigned one. She’s aware of that option, but rejects it as impractical.

“You can do that,” she said, “except if it’s a Medicaid person or a dual-eligible person, which is the highest percentage of people with disabilities, you’re not allowed to do non-assigned claims. And you can’t even do an ABN (Advance Beneficiary Notice of Non-Coverage) with them. So that means no access.”

The Costs to CRT

In addition to decreased access to life-changing CRT for consumers, misappropriation of codes leads to trouble for providers’ businesses and manufacturer wariness about innovation and product development, Stanley said.

“Just between coding descriptor changes and changes to what [CMS] claims is included in the base price, the industry lost over 20 percent in reimbursement over a 20-year period from Medicare,” she explained. “And that’s without any price reductions or price freezes. That’s just from coding and policy changes — the industry lost 20 percent.”

Providers who find it harder and harder to stay profitable so they can keep their doors open often don’t see the slow erosion that coding changes can cause.

“With the supplier, it’s not just him buying the item from [the manufacturer] and then it magically appears on the consumer’s chair and the bill just automatically gets to Medicare,” Stanley said. “There are costs. And especially with all the items [CMS] moved to capped rental, now not only do you have to bill it, but you’ve got to bill it 13 times.

“Most suppliers don’t really know what happened. They just suddenly wonder, ‘Why am I not making money doing this anymore?’”
So what’s the solution for providers who are losing the coding war via a thousand cuts, and manufacturers who are wary of developing new CRT products that will very likely be forced into an inappropriate and ill-funded code?

One answer would be the CRT industry’s separate benefit category effort, which would create a new benefit (and new HCPCS codes and allowables) for the seating and wheeled mobility products used by people with severe and permanent mobility-related conditions (see sidebar).

If and when that new benefit category is established, not only could existing coding problems be addressed — but increased differentiation could lead to more accurate equipment definitions that would reward innovation and reduce the temptation to manufacture cheaper products that just barely meet coding requirements.

An example is the existing K0005 manual wheelchair code.

“Think about the myriad models of ultralightweight wheelchairs,” Stanley said, “from titanium and carbon fiber to chairs that are literally built based on the specific person. Look at those rigid chairs versus a Quickie 2, where everything can be moved or adjusted, or it’s modular because you’re taking the person from the beginning phase of a disability all the way through as they morph and change, learn and grow, lose weight, gain weight. When you have a folding chair that’s modular, you have the ability to adapt as the person progresses or their disease progresses or they change.

“Then you get a person who’s been in a chair for a long time. They know exactly how they want to sit; they don’t want anything extra that’s going to come loose. And yet we have one code — K0005. But you’ve got a K0001, a K0002, a K0003, a K0004, a K0006, a K0007 that are all standard [wheelchair codes], for chairs that come in two basic sizes, no adjustability. There are all those codes for [standard chairs], but we have one.”

Ideally, Stanley suggested there could be different codes in the future to distinguish a rigid ultralightweight chair being ordered by a knowledgeable client with paraplegia who’s already had four previous chairs, and a newly injured client who’s just moved from the rehab hospital back to his parents’ home, is now gaining a little weight from Mom’s cooking, and is still learning how to transfer. Perhaps the catch-all K0005 code could spin off a new code for adjustable, folding ultralightweight chairs.

“We may even see a range that says if you’re talking about a folding chair that is for the new user, there may be all kinds of requirements in terms of adjustability and options and features, because you can’t really address the needs of that newly injured person if you don’t have some of that capability built in,” Stanley suggested. “And then you may see something different for people who just need [a chair] that’s between what today is a K0004 and a K0005. And then you want that individually configured and manufactured chair to meet the measurements of a specific person — when you’re getting into I want x degrees of bend on the front end, I want a taper on the front end, I want a certain back-angle degree, I want this much squeeze.

“If you look at the bucket today of what’s classified as a K0005, the only requirement is that it weighs less than 30 lbs., it has a lifetime warranty, you have to be able to adjust the rear wheels. It doesn’t say how you have to adjust them, or how far you have to adjust them. Do you have to adjust them vertically? Horizontally? Both? It’s not defined. So on the PDAC Web site, you’ll see chairs in there that have very little adjustability and just barely are under the 30-lb. mark, and then you’ll see chairs in there that weigh 17 lbs. and have a massive amount of adjustability.”

A separate benefit category could go a long way toward finally acknowledging the very precise, highly individualized measurements, adjustments and options that define CRT.

“Congress gets it,” Stanley said. “And I think that’s why we have the amount of support that we do for the separate benefit category now.”

This article originally appeared in the March 2018 issue of Mobility Management.